Factors influencing the incidence and prognosis of second primary tumors in patients with oral squamous cell carcinoma

Oral Squamous Cell Carcinoma and Concomitant Primary Tumors, What Do We Know? A Review of the Literature

Head and neck cancer is among the top ten cancers worldwide, with most lesions in the oral cavity. Oral squamous cell carcinoma (OSCC) accounts for more than 90% of all oral malignancies and is a significant public health concern. Patients with OSCC are at increased risk for developing concomitant tumors, especially in the oral cavity, due to widely genetically susceptible mucosa to carcinogenic factors. Based on fulfilling specific criteria, these concomitant tumors can be called second primary tumors (SPTs), which can be further categorized into metachronous and synchronous tumors. This research reviews the literature that investigated the concurrent OSCC with second or multiple primaries to improve understanding of the definition, classification guidelines, and its effect on cancer survival. It also highlights the current investigation methods, the variation of standard treatment approaches due to such a phenomenon, and preventive measures discussed in the literature.

Factors associated with the development of second primary tumours in head and neck cancer patients

INTRODUCTION

The development of second primary tumours (SPTs) is one of the main causes of low survival in patients with head and neck cancer (HNC). The aim of this study was to review the evidence about factors associated with developing SPTs in patients with HNC.

METHODS

An updated systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, and the search was performed in Pubmed and Scopus. Only original articles with a cohort or case-control design were included. Article quality was assessed with the Newcastle-Ottawa scale.

RESULTS

Thirty-six and two case-control studies were included, with quality medium (n = 5) to high (n = 33). Tobacco showed a significant association with SPT development, with risks ranging from 1.41 (95%CI: 1.04-1.91) to 5.52 (95%CI: 2.91-10.49). Regarding alcohol, risks ranged from 1.46 (95%CI: 1.12-1.91) to 21.3 (95%CI: 2.9-156). Location of the index tumour in the hypopharynx/oropharynx, absence of human papillomavirus and presence of a premalignant lesion also increased the risk of SPTs. More controversy was found for sex, age and other clinical factors of the tumour.

CONCLUSION

Toxic lifestyle habits and clinical factors were associated with the risk of SPTs in HNC patients. These findings may improve individualised prevention strategies in its follow-up.

Risk Factors for Esophageal Squamous Cell Carcinoma in Patients with Head and Neck Squamous Cell Carcinoma

Background

Esophageal squamous cell carcinoma (ESCC) is a common second primary neoplasia in patients with a history of head and neck squamous cell carcinoma (HNSCC). The aim of this study was to provide further information and novel insights into the risk factors for ESCC in patients with HNSCC.

Methods

We retrospectively analyzed 98 HNSCC patients diagnosed from 2007 to 2017, 30 HNSCC patients suffering from ESCC, who had undergone endoscopic examination because of positive imaging examinations or symptoms, and 68 HNSCC patients who had no ESCC occurrence for at least six years post-HNSCC diagnosis. Associated clinicopathological data and lifestyle information of the ESCC group and the without ESCC group were collected, and a case-control study of risk factors was analyzed between the two groups.

Results

The majority (83.4%) of the cases with HNSCC esophageal cancers were male patients over 50 years. We established that 93.75% (30/32) of the ESCC occurred within six years after HNSCC diagnosis. HNSCC location, stage, and radiotherapy history had no significant association with the development of ESCC. High Ki67 labeling index (Ki67 LI) (>46) patients tended to be 3.1 times (95% CI = 1.3–7.6) more likely to develop ESCC compared to low Ki67 LI (≤45) patients (P < 0.05). Drinkers with alcohol flushing response were at a 3.3 times higher risk to have ESCC (95% CI = 1.0–10.4) than drinkers without flush response (P < 0.05).

Conclusions

HNSCC patients, especially drinkers with an alcohol flushing response, as well as those with high Ki67 LI of HNSCC tissue, were more likely to develop ESCC.

Second Primary Malignancies in Patients with Pancreatic Neuroendocrine Neoplasms: A Population-Based Study on Occurrence, Risk Factors, and Prognosis

Background

This study aimed to evaluate the risk factors of developing second primary malignancies (SPMs) among patients with pancreatic neuroendocrine neoplasms (pNENs) and the prognosis of pNENs patients with SPMs (pSPMs) using data from the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

Data from patients diagnosed with pNENs between 1988 and 2016 were extracted. A case-control study was conducted to investigate the risk factors of developing SPMs among patients with pNENs. Meanwhile, cox regression analysis was also conducted to obtain the independent prognostic factors in pSPMs.

Results

Of 7,630 patients with pNENs, 326 developed SPMs. Patients with pNENs who had not undergone surgery and had been diagnosed in recent periods had a higher risk of developing SPMs. The following independent prognostic predictors for pSPMs were identified: age, latency period, SEER stage, radiotherapy, and surgery.

Conclusions

These findings may improve the surveillance of risk factors for developing SPMs in patients with pNENs and the prognostic risk factors in pSPMs.

Characteristics of esophageal cancer in patients with head and neck squamous cell carcinoma

BACKGROUND

We investigated the clinicopathological features of esophageal cancer in patients with a history of head and neck squamous cell carcinoma (HNSCC) with the intention of providing information regarding the characteristics of these patients.

METHODS

A retrospective study was performed in 32 cases of esophageal cancer with HNSCC who were diagnosed using upper gastrointestinal endoscopy between 2007 to 2017. Synchronous carcinoma (SC) group and metachronous carcinoma (MC) group was established based on whether esophageal cancer was diagnosed within 6 months after HNSCC diagnosis. The clinicopathological features of esophageal cancer and HNSCC, as well as follow-up treatment and survival, were analyzed in esophageal cancer patients in both groups.

RESULTS

There were 8 cases of 8 patients (7 males and 1 female) in the SC group and 24 cases of 22 patients (21 males and 1 female) in the MC group. The majority of esophageal cancer of HNSCC were male patients aged 50-69 years. The average interval time between diagnosis of esophageal cancer and HNSCC was 36.0±39.2 months (3.25±2.19 months for the SC group and 46.90±39.73 months for the MC group). Ninety-three-point-seven-five percent (30/32) of the patients had esophageal cancer within 6 years after HNSCC. The proportion of early esophageal cancer and successful surgical treatment in the SC group was significantly higher compared to the MC group (P<0.05).

CONCLUSIONS

Detection of esophageal cancer should be prioritized in HNSCC patients.

A cause-specific Cox model for second primary tumors in patients with head and neck cancer: A RONCDOC study

Background

The aim of this study was to identify risk factors for the development of second primary tumors (SPTs) in the head and neck region, lungs, and esophagus in patients with head and neck cancer.

Methods

We collected data from 1581 patients. A cause‐specific Cox model for the development of an SPT was fitted, accounting for the competing risks residual/recurrent tumor and mortality.

Results

Of all patients, 246 (15.6%) developed SPTs. Analysis showed that tobacco and alcohol use, comorbidity, and the oral cavity subsite were risk factors for SPTs. The C‐index, the discriminative accuracy, of the model for SPT was 0.65 (95% confidence interval, 0.61–0.68).

Conclusions

Our results show that there is potential to identify patients who have an increased risk to develop an SPT. This might increase their survival chances and quality of life. More research is needed to provide head and neck clinicians with definitive recommendations.

Incidence, timing, presentation, treatment, and outcomes of second primary head and neck squamous cell carcinoma after oral cancer

After their initial presentation of oral squamous cell carcinoma (SCC), patients have a lifelong risk of developing another new SCC of the head and neck. The aim of this study was to establish second primary rates, baseline characteristics (site, clinical or pathological stage, and smoking and alcohol history), timing, presentation, treatment, and outcomes. From the regional unit we analysed records of patients treated with curative intent for their first oral cancer between 2002 and 2007 inclusive. All patients had had at least 10 years of follow up either to death or the end of 2017. A total of 347 patients had been treated with curative intent, and of them, 29 had a second primary at a median (IQR) of 52 (30-79) months after the index operation. The incidence of developing a second primary tumour within two years was 1.7% (95% CI: 0.7% to 3.7%), within five years was 4.9% (95% CI: 2.9% to 7.7%), and within 10 years was 7.8% (95% CI: 5.1% to 11.1%). Early stage of first cancer was the only significant factor (p=0.001) for development of a second primary within 10 years, reflecting survivorship. Most second primaries (21 patients) were staged as early, and by visual inspection. Most (n=20) were within the oral cavity, one of which overlapped the oropharynx; eight others were in the oropharynx, and one in the larynx. Most patients (n=22) were treated by operation with curative intent. Three were treated palliatively. Patients need to be aware of the risk of a second primary and, as most are in the mouth or oropharynx, there is a role for surveillance by primary dental care practitioners.

Thymoma appearing 9 years after the resection of squamous cell carcinoma of the lip: A case report of triple primary tumors and literature review

The occurrence of second primary tumor (SPT)following malignancy treatment is common. In patients with head and neck (H&N) cancer, SPTs principally occur in the H&N region, lungs or esophagus. Therefore, patient follow-up after cancer treatment is important in order to detect recurrence, metastasis and new primary tumors. However, no standard guidelines on lifelong follow-up imaging are available. Herein, we report a patient who presented with three metachronous primary tumors-squamous cell carcinoma (SCC) of the tongue, SCC of the lip and type A thymoma. The third tumor was incidentally detected during follow-up using contrast-enhanced computed tomography (CT) 9 years following resection of the second tumor. To the best of our knowledge, this specific combination of metachronous tumors has not yet been reported. Based on the literature review, we observed that thymoma occurs following H&N cancer treatment. Therefore, to ensure that the presence of subsequent thymomas is not overlooked, we suggest regular lifelong follow-up using contrast-enhanced CT in patients who had previously been diagnosed with H&N cancer. The literature review revealed that thymomas occur in patients with H&N cancer and should be detected at the earliest convenience.

Second primary tumors in proliferative verrucous leukoplakia: a series of 33 cases

OBJECTIVES

To describe the number of second primary malignancies in a series of 33 patients with proliferative verrucous leukoplakia (PVL), detailing the mean time between primary malignancies and their clinical characteristics.

MATERIALS AND METHODS

Two groups of patients were included in this study: group 1 comprised 33 PVL patients who had developed ≥ 2 oral squamous cell carcinoma (OSCC) and group 2 comprised 48 PVL patients without malignant degeneration. We compared the groups with regard to age, gender, oral location, and number of oral sites affected. For patients in group 1, we determined the locations, clinical forms, and TNM stages of oral cancers. We also recorded the intervals of time between instances of oral cancer for all patients.

RESULTS

The groups did not differ significantly in age; however, group 1 included more women (p < 0.05). The follow-up period and number of oral PVL locations were greater in group 1 (p < 0.01). Moreover, in group 1, as the number of OSCCs increased, the intervals between them became shorter. The gingiva was the most common site. The mean number of cancers in group 1 was 3.15; five second primary tumors were diagnosed in one patient.

CONCLUSIONS

Multiple cancers in PVL patients were more frequently located on the gingiva in the form of erythroleukoplastic areas. In addition, the interval between new cancers decreased over time.

CLINICAL RELEVANCE

This is the series with the highest number of cases described with second primary tumors in PVL.

Hypermethylated ZNF582 and PAX1 genes in oral scrapings collected from cancer-adjacent normal oral mucosal sites are associated with aggressive progression and poor prognosis of oral cancer

OBJECTIVE

This study assessed whether hypermethylated ZNF582 and PAX1 genes in oral scrapings are correlated with the progression and prognosis of oral squamous cell carcinoma (OSCC).

MATERIALS AND METHODS

Methylation levels of ZNF582 and PAX1 genes in oral scrapings, collected from the cancer and adjacent normal oral mucosal sites of 80 OSCC patients before surgical cancer excision, were quantified using real-time methylation-specific PCR after bisulfite conversion.

RESULTS

Both the mean methylation (M)-indices of ZNF582 and PAX1 genes in oral scrapings were significantly higher at the cancer sites than at the adjacent normal oral mucosal sites (both P < .001). In the oral scrapings collected from the adjacent normal oral mucosal sites, the higher M-index of methylated ZNF582 (ZNF582^m) was significantly correlated with a more advanced clinical stage (P = .04). Moreover, the higher M-index of methylated PAX1 (PAX1^m) was significantly related to larger tumor size (P = .046). When the 80 OSCC patients were classified based on gene methylation tests, using the oral scrapings collected from the adjacent normal oral mucosal sites, we found a significantly shorter 3-year overall survival in ZNF582^m-positive, PAX1^m-positive, and ZNF582^m/PAX1^m-positive OSCC patients than in ZNF582^m-negative (P = .02), PAX1^m-negative (P = .04), and ZNF582^m/PAX1^m-negative OSCC patients (P = .02), respectively. Multivariate Cox regression analyses identified ZNF582^m and ZNF582^m/PAX1^m as independent unfavorable prognostic factors.

CONCLUSION

Hypermethylated ZNF582 and PAX1 genes in the oral scrapings collected from adjacent normal oral mucosal sites rather than cancer sites are associated with aggressive progression and poor prognosis of OSCC.

[Synchronous carcinoma of the floor of mouth carcinoma with esophageal carcinoma: a case report]

This study presents a case of synchronous multiple primary cancers involving floor of mouth carcinoma with esophageal carcinoma. Literature was reviewed to summarize the incidence, location, diagnosis, treatment characteristics, and prognosis to improve understanding and awareness of the multiple primary cancer. As a result, early discovery, early diagnosis, and effective treatment can help prolong survival and improve the quality of life of patients.